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. 2009 Sep 16;6(Fall):1g.

Healthcare fraud and abuse

William J Rudman  1 , John S Eberhardt 3rd, William Pierce, Susan Hart-Hester
Affiliations

Healthcare fraud and abuse

William J Rudman et al. Perspect Health Inf Manag. .

Abstract

In Texas, a supplier of durable medical equipment was found guilty of five counts of healthcare fraud due to submission of false claims to Medicare. The court sentenced the supplier to 120 months of incarceration and restitution of $1.6 million.

Raritan Bay Medical Center agreed to pay the government $7.5 million to settle allegations that it defrauded the Medicare program, purposely inflating charges for inpatient and outpatient care, artificially obtaining outlier payments from Medicare.

AmeriGroup Illinois, Inc., fraudulently skewed enrollment into the Medicaid HMO program by refusing to register pregnant women and discouraging registration for individuals with preexisting conditions. Under the False Claims Act and the Illinois Whistleblower Reward and Protection Act, AmeriGroup paid $144 million in damages to Illinois and the U.S. government and $190 million in civil penalties.

In Florida, a dermatologist was sentenced to 22 years in prison, paid $3.7 million in restitution, forfeited an addition $3.7 million, and paid a $25,000 fine for performing 3,086 medically unnecessary surgeries on 865 Medicare beneficiaries.

In Florida, a physician was sentenced to 24 months incarceration, ordered to pay $727,000 in restitution for cash payments where the physician signed blank prescriptions and certificates for medical necessity for patients he never saw.

The U.S. Department of Health and Human Services (HHS) Office of the Inspector General (OIG) found that providers in 8 out of 10 audited states received an estimated total of $27.3 million in Medicaid overpayments for services claimed after beneficiaries' deaths.

Keywords: computer assisted coding; data mining; fraud and abuse.

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Figures

Figure 1
Figure 1
Bayesian Belief Network of Healthcare Claims Fraud
Figure 2
Figure 2
Reference Distributions
Figure 3
Figure 3
Evidence Input: Changed Physician
Figure 4
Figure 4
Evidence Input: Committed Fraud
Figure 5
Figure 5
Probability of Fraud with Change in Physician But Limited Encounters
Figure 6
Figure 6
Receiver Operating Characteristic Curve Optimized toward Sensitivity
Figure 7
Figure 7
Receiver Operating Characteristic Curve Optimized toward Specificity
See this image and copyright information in PMC

References

Notes

    1. U.S. Department of Health and Human Services and Department of Justice. Health Care Fraud and Abuse Control Program Annual Report for FY 2007 (2008). Available at http://oig.hhs.gov/publications/docs/hcfac/hcfacreport2007.pdf
    1. U.S. Department of Health and Human Services and Department of Justice. Health Care Fraud and Abuse Control Program Annual Report for FY 2007 (2008). Available at http://oig.hhs.gov/publications/docs/hcfac/hcfacreport2007.pdf
    1. U.S. Department of Health and Human Services and Department of Justice. Health Care Fraud and Abuse Control Program Annual Report for FY 2007 (2008). Available at http://oig.hhs.gov/publications/docs/hcfac/hcfacreport2007.pdf
    1. U.S. Department of Health and Human Services and Department of Justice. Health Care Fraud and Abuse Control Program Annual Report for FY 2007 (2008). Available at http://oig.hhs.gov/publications/docs/hcfac/hcfacreport2007.pdf
    1. U.S. Department of Health and Human Services and Department of Justice. Health Care Fraud and Abuse Control Program Annual Report for FY 2007 (2008). Available at http://oig.hhs.gov/publications/docs/hcfac/hcfacreport2007.pdf

References

    1. Geis G, Jesilow P, Pontell H, O'Brien M.J. “Fraud and Abuse of Government Medical Benefit Programs by Psychiatrists.”. American Journal of Psychiatry. 1985;142:231–34. Available at http://ajp.psychiatryonline.org/cgi/content/abstract/142/2/231. - PubMed
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Penalty

    1. Morrison James, Wickersham Peter. “Physicians Disciplined by a State Medical Board.”. Jo urnal of the American Medical Association. 1998;279(23):1889–93. Available at http://jama.ama-assn.org/cgi/reprint/279/23/1889. - PubMed
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Coding

    1. Kassirer, Jerome P., and Marcia Angell. “Evaluation and Management Guidelines—Fatally Flawed.” New England Journal of Medicine 339, no. 23 (December 3, 1998): 1697–98. Available at http://content.nejm.org/cgi/content/full/339/23/1697 - PubMed
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Software

    1. Phua, C., V. Lee, K. Smith, and R. Gayler. “A Comprehensive Survey of Data Mining-based Fraud Detection Research.” Available at http://clifton.phua.googlepages.com/fraud-detection-survey.pdf
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Legal/Law

    1. Klein, R. D., and S. Campbell. “Health Care Fraud and Abuse Laws.” Archives of Pathology and Laboratory Medicine 130 (August 2006): 1169–77. Available at http://arpa.allenpress.com/pdfserv/10.1043%2F1543-2165(2006)130%5B1169:H... - PubMed
    1. Blumstein, J. F. “Rationalizing the Fraud and Abuse Statue.” Health Affairs 15, no. 4 (Winter 1996): 118. Available at http://content.healthaffairs.org/cgi/reprint/15/4/118 - PubMed
    1. Stanton T.H. “Fraud and Abuse Enforcement in Medicare: Finding Middle Ground.”. Health Affairs. 2001;20(no. 4):28. Available at http://content.healthaffairs.org/cgi/reprint/20/4/28. - PubMed
    1. Blumstein, J. F. “The Fraud and Abuse Statute in an Evolving Health Care Marketplace: Life in the Health Care Speakeasy.” American Journal of Law & Medicine 22 (1996): 205. Available at http://scholar.google.com/scholar?hl=en&lr=&q=info:kLN_Up_YkXkJ:scholar.... - PubMed
    1. Glauser, J. “The False Claims Act Rewards Greed, Not Honest Attempts to Comply with Coding Guidelines.” Emergency Medicine News 24, no. 5 (May 2002): 26, 28. Available at http://www.em-news.com/pt/re/emmednews/fulltext.00132981-200205000-00018...

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